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Friday, April 18, 2014

Catching a hidden error, before it counts.

Sitting in a recliner at 3:00 am recently, listening to radio traffic from several helicopters on transports, I heard one fellow call-off from his base, obtain coordinates for a scene, and then, after arriving at his destination, call to say no one was there.

He asked the communications specialist to check on the coordinates for accuracy and was told to stand-by. After a few seconds of silence, he came back on the radio and said, "disregard, we have the correct numbers now and are proceeding to the scene - we are about 3 minutes out." He had incorrectly entered the numbers that his crew copied and read to him.

I have done the same thing. You get in a hurry entering data, and you punch the wrong button or roll the wrong number. This type of mistake led to the Russians shooting down a KAL jet. Fatigue contributes to these types of errors.

Because we fly HEMS, we frequently check our info and dart out the door.

Occasionally we head to the wrong place. Once a pilot arrived at Ridgeland (SC), when he was supposed to be going to Richland. Ridgeland is a town near Beaufort, and Richland is a hospital in Columbia. I was given the heading and distance to Estill recently, when I was supposed to be going to Edisto - the similar sounding name confused my comspec - and me. The paramedic caught the mistake by looking out the window.

Spoken communication is an imperfect process.

Not long ago I was pushing toward the end of a 16 hour day, and although I said I felt fine subjectively, the truth is I was fatigued.Objectively, my performance was degraded. Fatigue has both subjective and objective components. How we feel versus how we perform.
I wanted to get it over with as soon as possible. (Get-home-itis) As I loaded my destination into my GPS I entered a couple of characters, the box finished filling the field, I saw the name of my destination-town in the display and pressed direct-to.

Unfortunately, I had selected the wrong airport in that town (there are two). When I got there, I spent a few seconds with a lack of situational-awareness as I tried to make the pieces fit together amidst confusion, discomfort, and fatigue...

I made my error at the beginning of my flight, and it didn't show up till near the end. Just like that KAL jet. I had all the time in the world to discover it.

If one person is doing it, other people are doing it too.So what can we do about this early-mistake problem?

How about, after darting out to the aircraft, and once established in cruise flight, we do a "DART" check.

Destination - lets all agree that where we think we are going is where we are supposed to be going. Check the heading and distance in the GPS against what was originally transmitted and also against what we are all familiar with - medics who work the ground before flying are a great resource regarding what is where. Restate the name of the destination, be it a city/town or a hospital in a city/town.

Altitude - is the altitude we are at appropriate for the patient, terrain, weather, and winds aloft? And what about that highest-obstacle we checked before leaving? When a helicopter lost it's engine recently while cruising at 500 feet above the ground, it had about 10 seconds until touchdown. Altitude equals time to think, talk, recover rotor rpm, and make it to a suitable landing spot. Why do we helicopter pilots persist in flying so low?

Route - Once things settle down enroute, lets take another look at the map and make sure that the route of flight isn't going to penetrate any special-use airspace or airport traffic area we didn't think about. This is also a good time to talk about any nuke plants in the area. We may be questioned if we fly near one.

Time - Is the time required, now that we are in the wind, still going to work with the fuel on board? Do we still have enough drugs and O2? In one large HEMS company, O2 is now a hot-button issue. Can you guess why?

Most of us already do some sort of level-off or cruise-check, making sure that all systems are go. Adding these other checks to the routine, using this mnemonic as part of your level-off or cruise check may prevent disappointment or disaster.

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About Me

I am a retired army aviator, and flew EMS helicopters from 1999 until 2015. I have flown at many different programs under traditional, community based, and hybrid models. I enjoy interacting with crewmembers as we together learn how to avoid becoming a statistic and the topic of someone else's safety brief. I teach Air Medical Resource Management, and am a member of the National EMS Pilot's Association's board of directors.